Cardiac testing for coronary artery disease in potential kidney transplant recipients

Stress testing in patients with chronic kidney disease: The need for ancillary markers for effective risk stratification and prognosis

“…12 Fundamental to this controversy is the low sensitivity of stress testing in the CKD/ESRD cohort compared with subjects without CKD (Table 1). 13 Exercise electrocardiography (EKG) (treadmill or bicycle) is used in a minority of patients with CKD/ESRD as the prevalence of abnormal baseline EKG is high due to the presence of left ventricular hypertrophy, left bundle branch block, and ST-T changes that are either nonspecific or due to electrolyte abnormalities. Moreover, the exercise capacity of patients with CKD/ESRD is limited due to muscle fatigue, anemia, peripheral vascular disease, peripheral neuropathy, and other comorbidities.…”

“…In addition, the sensitivity and specificity of exercise electrocardiography in CKD/ESRD patients is poor (Table 1). 13,14 Similarly, the sensitivity and specificity of myocardial perfusion single photon emission computed tomography (SPECT) to detect CAD in CKD/ESRD patients are highly variable. In a prospective study of 138 patients referred for pre-renal transplant cardiac evaluation (43% on dialysis) and underwent coronary artery calcium score, coronary computer tomography angiography, and SPECT, SPECT had a low sensitivity (53%) and modest specificity (82%) for detecting obstructive CAD (C50% stenosis).…”

“…Finally, in a meta-analysis of nine studies of myocardial perfusion SPECT in potential kidney transplant recipients, the pooled sensitivity was 74% with a pooled sensitivity of 70%, both with wide confidence intervals ( Table 1). 13 The reason for reduced sensitivity of myocardial perfusion SPECT in CKD/ESRD patients is not clearly known but has been attributed to a number of mechanisms 16 : (a) ''balanced ischemia'' due to multivessel disease resulting in global ischemia. Patients with CKD have increased prevalence of multivessel disease.…”

Coronary Revascularization in Patients with CKD Stage 5D: Pragmatic Considerations

“…In a pooled analysis of smaller studies comparing dobutamine stress echocardiography with myocardial perfusion imaging (MPI), 13 both modalities had moderate sensitivity/ specificity for detecting CAD among renal transplant candidates. The authors concluded that dobutamine stress echocardiography was more accurate than MPI when all studies were included ( Figure 2).…”

“…The authors concluded that dobutamine stress echocardiography was more accurate than MPI when all studies were included ( Figure 2). 13 The decrease in microcirculatory flow reserve in CKD has been postulated to reduce the responsiveness to vasodilation with MPI. Winther et al 14 prospectively studied 138 patients (43% on dialysis) undergoing pretransplant evaluation by obtaining MPI, computed tomography coronary angiography (CCTA), coronary artery calcium (CAC), and invasive coronary angiography on every patient.…”